The body which reviews the deaths of children known to care services has urged the government to address the lack of adequate mental health services after outlining how it has been a factor in some of the cases it has reviewed.
The National Review Panel looked at 13 deaths of children known to care services in 2018 - a fall of nine compared to the figure for 2017 - but also looked at patterns among the 184 deaths it has reviewed since February 2010.
The NRP, chaired by Dr Helen Buckley, reviews cases where a serious incident or death occurs of children or young people under 18 who are in the care of the state, or have been known to the Child and Family Agency’s social work department or funded services.
In addition to its annual report, it also published four new individual report, including one for a boy named Simon which highlighted "tensions" between social workers and the district court over care orders, a "risky" initial focus on family reunification when a foster placement would have been preferable, and deficits in care over how an allegation of peer sexual abuse was made against the boy - then aged just seven.
Of the 13 such deaths in 2018, 10 were females.
Eight of the 13 deaths were from natural causes, there were three suicides, while one was as a result of an accident and the cause of another was unknown.
Just one person was in care at the time of their death, although there were to other serious incidents brought to the attention of the NRP involving children in care. Six of those who died in 2018 were aged under one and seven deaths occurred in one area - Dublin North East.
One infant was stillborn and another infant died from SIDS while co-sleeping. Both of their mothers had been misusing drugs in pregnancy.
Regarding issues among the cases, it said parental inability to manage their child's behaviour was a factor in some cases.
"In one of these cases, the young person was in urgent need of a residential autism service, and the lack of such a service put his safety at risk and strained his parents’ capacity to protect him," the NRP said.
The lack of adequate mental health services and the mismatch between the expectations held of CAMHS (Child and Adolescent Mental Health Services) and the reality of what this service is prepared to offer are themes that have recurred frequently since the NRP was established.
"This very significant deficit is outside the capacity of Tusla to resolve and needs attention from the government."
Terry Dignan CEO of Empowering People in Care (EPIC) agreed and said there needed to be better interagency cooperation, describing CAMHS as a "shambles".
He said there needed to be an appropriate and comprehensive mental health assessment for every child going into care and said work was now needed to future-proof the system in light of the number of homeless children who may need care intervention.
Dr Buckley said there was often evidence of good practice but in some other instances, early responses to referrals were "slow and fragmented", while some reports were given a less serious classification than was warranted.
The report also showed 184 deaths notified to the NRP between February 2010 and the end of December 2018, with natural causes the factor in 40% of those cases.
Simon was in his late teens when he died in a road traffic incident overseas, having left state care here some months earlier.
A member of the Travelling Community, Simon's early years were marked by neglect and he was "damaged" by abuse. He was first the subject of an interim care order and later a full care order, with at least 20 short-term foster placements between his fourth and sixth years.
He needed a secure and stable foster placement, seen as his "best opportunity", but his parents opposed it. According to the review:
"It also required legal protection to minimise the efforts of his birth parents to undermine it, which was not available. It took a number of years for the District Court to issue a full care order leading to legal uncertainty in the management of this case.
"By the time of the end of his foster placement, there is evidence that he had begun to actively model some of the criminal and anti-social aspects of his birth parents’ lifestyle."
Simon needed a secure, intensive, residential environment in the care system with tight management of parental contact - "this was not available at the time".
There followed a period in youth detention, spells in homeless accommodation and an adult prison sentence.
The NRP said there was a delay by the SWD in seeking a full care order on Simon when he first came to attention and the initial focus on family reunification was "extremely risky".
While the initial district court ‘mid-term’ order until his 13th birthday was seen as flawed, it wasn't appealed because of previous limited success with similar applications.
The management of a sexual abuse allegation implicating Simon when he was just seven was "very problematic, and constitutes a breach of good practice".
He was not notified as a victim and was interviewed as an alleged perpetrator some eight years later. The NRP said:
Guidance required the SWD to implement child protection procedures at this time to assess his needs as a child, which it failed to do.
"The recording of the incident is very poor, and the outcome is not recorded."
While the NRP found some evidence of good practice in the case, it also said lessons needed to be learned including in managing acute parental conflict, and ensuring that all contentious cases are subject to due process of appeal, "and are appealed rigorously".
It also said there should be protocols to strengthen the implementation of Contact Orders by SWDs.
Ray was three years old when he died. Both of Ray's parents had drug addictions and he was listed on the child protection notification system.
The case was transferred between different social work teams and the SWD was under "severe pressure at this time". Sometimes there was very little contact between the SWD and Ray's mother and her family. Several months passed before an assessment took place.
Ray was later delisted from the CPNS due to extended family support.
With his pregnant mother in a detox unit, Ray was cared for by his grandparents and at weekends by his father. He died as a result of an accident while in the care of his father, who had a number of substances in his system at the time.
While there was much good practice in the case, the NRP cited high social worker turnover and a lack of consideration of Ray’s father’s parenting ability.
Eddie was nearly 16 when four referrals about him were received by the Tusla SWD over a period of three weeks - from Gardaí, his school, CAMHS and his GP.
One related to a school refusal and him not being deemed eligible for Tusla services, the others regarding an incident where he had been wandering around a town at night.
He had been referred to CAMHS but was considered ineligible. The SWD referred him to the Prevention, Partnership and Family Support Service (PPFS) for support.
Tragically, Eddie died in a fatal accident shortly after the service was offered to him.
The NRP said there was no evidence that this was affected by the availability or quality of a service but said the absence of immediate risk to a child’s safety does not negate the need for an initial assessment where a referral indicates welfare concerns.
Fiona, 9, died from a long-term serious illness. She and her family had received services from Tusla over a two-year period, having been referred by the medical social work service in the hospital over concerns about her parents’ apparent non-compliance with her treatment programme.
Fiona’s parents said they found it distressing to give her medication because of its side effects and her own resistance to taking it. However, they were providing good care and undertook to comply.
A further referral was made eight months later after Fiona’s blood tests indicated that she was not getting her full dosage.
A social worker found that her parents needed emotional support, but there was a delay of several months before a family support worker was appointed because of a lack of resources.
Fiona went into hospital for supervised treatment but sadly passed away nine months later. The NRP found good practice but said opportunities for better interagency working were missed.